Spirit India

At a time when the U.S. spends more than double what other countries spend for medical care—$6,697 per capita in 2005—a new Commonwealth Fund seven-nation survey finds that U.S. patients are more likely to report experiencing medical errors, to go without care because of costs, and to say that the health care system needs to be rebuilt completely.

U.S. patients, along with Canadians, are also the least likely to be able to get a same-day appointment with their physicians when sick and the most likely to seek care in emergency rooms as an alternative. The study, published today in a Web Exclusive in the journal Health Affairs, finds that U.S. adults also have the highest out-of-pocket costs and greatest problems paying medical bills.

In the survey of 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States, one third of U.S. adults called for rebuilding the system, the highest rate in any country surveyed. The U.S. also ranked last in saying only minor changes are needed in the health system.

In addition to cost concerns, U.S. patients report more fragmented and inefficient care, including medical record and test delays, perceptions of waste and more time spent on paperwork, compared to patients in other countries.

“As policymakers and the public consider proposals for fundamental change, there are lessons to be learned from looking abroad. This survey shows that patients in the U.S. are frustrated by high costs and a complicated health care system,” said Commonwealth Fund Senior Vice President Cathy Schoen, lead author of the article.

In terms of patient safety, adults in the U.S. report the highest rates of lab test errors and among the highest rates of medical or medication errors. Patient-reported errors were highest for those seeing multiple doctors or with multiple chronic illnesses. One-third of U.S. patients with chronic conditions reported a medical, medication, or test error in the past two years.

Despite assertions by some that universal insurance systems result in long waits for care or “rationing,” only Canada (22%) ranked behind the U.S. (30%) in the low percentage of patients saying they could get same-day appointments with their doctor when they are sick. In contrast, half or more of patients in Germany, the Netherlands, and New Zealand report rapid access to physicians. Notably, in the U.S and Canada, along with Australia, two-thirds or more reported difficulty getting care on nights, weekends, or holidays—the highest rates in the survey.

Easy access to elective surgery has also been cited as a benefit of the U.S. health care system. Yet, similar to the U.S., the majority of patients in Germany, New Zealand, and Australia waited less than a month for elective or non-emergency surgery and waits of 6 months or more were rare in these countries and the Netherlands. In Canada and the U.K., about 15 percent of patients reported waits of more than six months for elective or non-emergency surgery. In the U.K., waits dropped dramatically compared with the 2001 Commonwealth Fund International Health Policy Survey, when 28 percent reported waiting more than six months for elective surgery.

U.S. Patients Face Cost-Related Access Barriers

As in previous surveys, U.S. adults were most likely to have gone without care because of cost and to have high out-of-pocket costs. In the U.S., nearly two of five (37%) of all adults and 42% of those with chronic conditions had skipped medications, not seen a doctor when sick, or foregone recommended care in the past year because of costs—rates well above all other countries. In contrast to the U.S., patients in Canada, the Netherlands, and the U.K. rarely report having to forgo needed medical care because of costs.

In addition, one-fifth of U.S. adults report serious problems paying medical bills—more than double the rate in the next highest country. And nearly one third (30%) in the U.S. spent more than $1,000 in the past year out-of-pocket—a level rare in most of the other countries.

The U.S. also stands out for symptoms of more fragmented and inefficient care:

One of four U.S. adults report coordination problems, either medical records not available during their doctor visit or duplication of tests—the highest rate of any country in the survey.

One of five U.S adults report a time doctors recommended treatment the patient thought had little or no benefit; this rate was also high in Germany.

Only the Netherlands (31%) topped the U.S. (24%) for the percentage of people who spent time on paperwork or disputes related to medical bills or insurance. In the other countries, fewer than 15 percent reported this concern.

In the past two years, 36% of U.S. adults visited an emergency room; only Canada had a higher rate (39%). In both the U.S. and Canada, about 40 percent of those with an emergency room visit said the visit was for a condition that could have been treated by their regular doctor if available.

“Medical Homes” Improve Care Coordination and Patient Satisfaction

As medical care becomes more specialized and complex, adults in all seven countries said they place high value on having a relationship with a regular source of primary health care that is accessible and coordinates their care. To assess the extent to which such relationships exist, the study identified patients as having such a “medical home” if they had a regular source of care that knows their medical history, is easy to contact, and helps coordinate care received from other providers.

Across very different country health care systems, the study found that only 45 to 61 percent of adults described having a primary source of care with these key attributes of a medical home.

In all countries, patients with such medical home relationships reported significantly more positive experiences, including having more time with their doctors, more involvement in care decisions, and better coordination with specialists and hospitals.

Those with a medical home were also much less likely to report medical errors, receiving conflicting information from different doctors or to encounter coordination problems, such as diagnostic tests or medical records not being available at the time of care and duplicate tests.

In the U.S., uninsured adults were at high risk of being without such a connection to the health system: just 26 percent of uninsured compared to 53 percent insured adults under age 65 had a medical home.

“The lack of a link to care as well as insurance puts the uninsured at double jeopardy for both inefficient care and access barriers. Health systems designed to create medical homes could help improve patient safety, coordination of care and reduce reliance on emergency rooms, while also improving patient satisfaction,” said Commonwealth Fund President Karen Davis. “The potential gain has led to endorsement of the medical home concept among U.S. primary care physicians, including the American Academy of Family Physicians and the American Academy of Pediatrics.”

The authors conclude, “As countries confront the question of how best to organize care systems to achieve higher value, the study highlights the importance and potential of having a relationship with a primary care source with characteristics of a medical home.”